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C-Leg®compact / C-Leg® Leg Prosthesis System · Patient Data
Fax to the addresses of our branches throughout
the world, which are listed at the end of this catalog.
Billing Address
Shipping Address (if different than billing address)
Customer no.
Customer no.
Company
Company
Address
Address
Orthopedic technician
Com.
Prosthesis user - Mobility Grade
Prosthesis user
Mobility Grade 2
Name __________________________________________
Age ____________________________________________
Mobility Grade 3
Sex
male
female
Mobility Grade 4
Weight _______________________________________kg
Size _________________________________________ cm
Knee – floor___________________________________ cm
Amputationsniveau
Socket – floor _________________________________ cm
Knee Disarticulation
Foot size _____________________________________ cm
Transfemoral
Hip Disarticalation
Color of footshell
beige
light brown
Side of amputation
left
right
Bilateral amputation
yes
no
Osseointegration
yes
no
Initial fitting with a C-Leg®compact / C-Leg®
Follow-up fitting with a C-Leg®compact / C-Leg®
The C-Leg®compact / C-Leg® leg prosthesis system is only offered as a complete system.
The General Terms and Conditions of Otto Bock HealthCare GmbH apply.
Date _____________
272
Place _____________________________
Signature ___________________________________
Otto Bock HealthCare GmbH | Prosthetics – Lower Extremities | www.ottobock.com
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C-Leg®compact / C-Leg® Leg Prosthesis System · Order Form
C-Leg®compact
C-Leg® (incl. Wireless Remote Control)
qty.
3C96 C-Leg®compact
qty.
3C98-1 C-Leg®
qty.
3C86 C-Leg®compact for long residual limb
qty.
3C88-1 C-Leg® for long residual limb fittings
Warranty
include 60-month warranty for C-Leg®compact/C-Leg® (incl. service in the 24th and 48th month)
Electronic Tube Adapter (minimum order quantity: 1)
qty. 2R80 (Standard) for C-Leg®compact / C-Leg®
Length of
110 mm (Max. 100 kg)
120 mm
160 mm
200 mm
240 mm
tube adapter:
qty. 2R81 (Torsion Unit) for C-Leg®compact / C-Leg®
Length of tube adapter:
160 mm
200 mm
240 mm
Connection components (minimum order quantity: 1)
qty.
4R57 Rotation Adapter
qty. 4R43 Lamination Anchor with Threaded Connector (3-prong)
qty. 4R57=ST Rotation Adapter with Thread
qty.
4R104=60 Double Adapter, movable
qty.
4R104=75 Double Adapter, movable
qty.
4R40 Torsion Adapter
qty.
4R118 Adapter Plate
qty. 4R89 Lamination Anchor with Pyramid Adapter (3-prong)
qty. 4R41 Lamination Anchor with Pyramid Receiver (3-prong)
qty. 4R111=N Lamination Anchor with Threaded Connector (4-prong)
qty. 4R116 Lamination Anchor with Pyramid Adapter (4-prong)
qty. 4R111 Lamination Anchor with Pyramid Receiver (4-prong)
Foot parts (minimum order quantity: 1)
qty.
1C40 C-Walk® prosthesis foot
qty.
1C30 Trias prosthesis foot
qty.
1D10 Men’s Dynamic Foot with Toes (incl. 2R31 and 2R14)
qty.
1D11 Women’s Dynamic Foot with Toes (incl. 2R31 and 2R14)
qty.
1D35 Dynamic Motion Foot
qty.
1A30 Greissinger plus
qty.
1E57 Lo Rider
qty. 1E56 Axtion®
24-25 cm
26-30 cm
max. 70 kg 24-25 cm
22-25 cm
24-25 cm
+ Footshell
max. 85 kg 23-34 cm
22-25 cm
25-26 cm
27-30 cm
26-28 cm
26-30cm
26-29cm
max. 136 kg/
+ Footshell
Additional Information for 1E57 and 1E56:
Impact load / Activity:
Footshell:
left
right
Mobility Grade 3
Stiffness/Flexibility:
stiff
medium
Moderate activity and low impact load
Moderate activity and moderate impact load
Mobility Grade 4
Moderate activity and high impact load
High activity and high impact load
qty. 4X160 Protector
soft
dolphin (=1.2)
blue (=5.6)
qty. 4X74 12 V Car-Charger Cable for 4E50-2
qty. 4X78 Charger Extension Cable
qty. 3S26 Standard foam cover
qty. 4X79 Plug Holder
qty. 3R59 Customized foam cover
(Please use separate order form)
AC Adapter (minimum order quantity: 1 of each)
qty. 757L16-2 AC Adapter
Date _____________
qty.
4E50-2 Battery Charger for C-Leg®compact / C-Leg®
Place _____________________________
Signature ___________________________________
Otto Bock HealthCare GmbH | Prosthetics – Lower Extremities | www.ottobock.com
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